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Achieving Population Health – the Power of Team-Based
Care
JAMES JERZAK, MD | PHYSICIAN LEAD,
TEAM-BASED CARE
AMERICAN CONFERENCE ON PHYSICIAN HEALTH
PRACTICE TRANSFORMATION BOOT CAMP
SEPTEMBER 18, 2019
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1. Understand the need for Team-based care
2. Understand three fundamentals of Bellin’s
model of Team-based Care
3. Learn how empowered staff provides
enhanced support for clinicians
4. Understand challenges to team-based care
transformation and how to overcome them
5. Understand how this model of care is
financially sustainable in any type of practice
Objectives
GREEN BAY, WISCONSIN
Bellin Health Overview
Realization of the Significant Impact of
Burnout on the organization
Call to Action:
• Planning Team formed
• Site Visits
• Literature review
• Solidify administration support
• Prototype launched November 2014
• Spread begins May 2015
Bellin Health’s
Journey to
Team-based
Care begins:
2014
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• Too much work being done below the top of their skill
set for all staff
• EHR demands on the clinician during the office visit
• Inefficient in basket with most work defaulting to
physician
• Challenge of providing comprehensive care to
increasingly complex patients
Bellin’s
Perspective:
Causes of
Burnout and
Inefficient
Care
Allocation of Physician Time in
Ambulatory Practice
• During a typical office day 27% of total time in direct
face time with patients, 49.2% of time spent on EHR
and desk work
• While in the exam room, 52.9% of time in face to face
interaction, 37% focused on the EHR
• 1-2 hours of after-hours work at night on EHR
Sinsky et al. Ann Intern Med.
2016;165(11):753-760
Clerical Demands of
EHR Work on
Physicians
Distraction:
“Like Texting
When Driving”
Work/Life
Imbalance:
Pajama Time
• Increasing copays and deductibles
• Increasingly complex patients in the
ambulatory setting
• Alternative settings for less
complicated patients – retail care,
urgent care, employer clinics, virtual
visits
• Increasing emphasis on quality
measures
“Chronic disease has become the great epidemic of our times”
Milani, et.al. Am J Med 2014.10.047
Increasing
Complexity of
Ambulatory Care
“Recently, there has been a shift
from viewing burnout as an
individual problem to a problem of
the health care organization as a
whole.”
Panagioti, et al JAMA IM 2017:177(2) 195-205
“……reducing burnout in
physicians requires change in
organizations”
Br J Gen Prac 2015:65(639)e708-e710
• The EHR burden on clinicians had to be
addressed
• Care teams need robust support to care
effectively for high risk and complex
patients.
• All staff needs to work up to their highest
skillset
• Advanced Team-based care provides the
foundation for successful transition to
value based payments
Conclusions from
Bellin’s Planning
Process,
November 2014
Our Solution:
Achieving Population Health
through Team-Based Care
1
7
Definition
Advanced Team-Based Care: A comprehensive approach to health care delivery transformation including
• Office visit redesign• In between visit redesign• Population Health Management
redesign, with seamless transitions of care between all system and community resources, to achieve optimal health and wellbeing for our entire patient population
Complete Redesign
of the Office Visit
First Element of
Transformation
ENHANCED ROLE
OF EMPOWERED
CMA’S/LPN’S
New Title: CTC
Care Team
Coordinator
Expanded CMA/LPN roles
• Care gap closure
• Med review/Pending refills
• Patient agenda setting
• Team documentation
• EHR work during visit; pending orders, referrals, etc
• Appointment scheduling – labs, future appointments, tests
• Review After Visit Summary: Teach back
Watch For:
• Enhanced role of empowered LPN/CMA
• Ability of the physician to focus on the patient
• Engagement of the patient with the LPN/CMA
Video:
Complete
Redesign of
Office Visit
Scribes
• Often limited term, not licensed to assist with patient care
Up trained staff
• Usually CMAs or LPNs can show:
• Enhanced engagement with patients
• Ability to provide more robust support to clinician
• Improved satisfaction of staff in this role
• Documentation equal to or better than physicians
Understand the
Differences
Redesign of Between Visit WorkSecond
Element of
Transformation
• Overwhelming numbers of items and folders
• Physician/ APC usually the default location for most in basket work
• Workflows and responsibilities are often undefined or unclear
• Lack of empowerment, support, and trust of team by physician in handling in basket tasks
So What’s the
Problem?
• Reorganize the in basket to streamline work
and eliminate unnecessary messaging
• Make sure planned care principles such as
pre visit labs are done consistently
• Route messages to most appropriate team
member who can handle the work at the top of
their skill set
• Filter out items not directly relevant to patient
care
• Establish team pools to streamline work
• Utilize the emerging principles of Team-Based
Care to empower team members to contribute
in meaningful ways to in basket management
General
Approach
• Promote Team Culture. Mature teams
make every minute count, and help out
other teams at every opportunity
• Take advantage of Co-location, use verbal
communication as much as possible
• Daily Huddles to anticipate and plan for
the day
• Empower your staff, and trust them to
perform work at the top of their skill set
Leverage
Team Based
Care
Principles
Things to watch for:
• Enhanced communication between team members• The value of the daily huddle• The value of pre visit preparation• Effective result management by the team• Key role of co-location
Video 2:
Redesign of
In Between
Visit Work
Youtube:
Bellin
Health
Team-based
care
Key Role of
Co location
Key Role of
Co location
• Ability to perform and bill patient visits:
• Resource for diabetes education
• Active role in CCM and TCM programs
• Facilitating care team meetings
• Active in quality measure improvement
• Oversees in basket work
• Resource for MA/LPNs
• Still need to do triage but…’triage is a failure of access’
Don’t forget your RN’s!
Population Health Management
Leveraging system and/or community resources to improve your patients’ health
Third Element
of
Transformation
Team-based
Care across
the System
Population Health Management
Leveraging system and/or community resources to improve your patients’ health
Third Element of
Transformation
• Team approach to quality measure improvement
• Involvement of Extended Care Team with complex patients (Clinical Pharmacists, RN Care Coordinators, Case Managers, Diabetic Educators to enhance the care of complex patients
• Delegate visits to other less costly care team members (i.e. RN for BP checks)
• Engagement with employers, payers, and community to provide care across the spectrum
How do
Teams
accomplish
Improved
Population
Health?
Regular
Care Team
Meetings
Old Model of
Patient Care
Advanced
Model
Of Care
Patient with Abnormal Glucose
Primary Care Core Team
Endocrinology Core Team
Low
HgB A1C
High Hg
A1C
Basic Education
Lifestyle
Education
Oral
Medications
Advanced
Education
Injectable
Medications
Complex Social
Needs
Complex
Medical Needs
Complex
Psychological
Needs
Uncontrolled
Diabetes Despite
Extended Care
Team Involvement
Motivational Interviewing Health Coaching Goal Setting
Community Resources
Care
Team RNClinical
Pharmacist
Diabetes
Services
Case
Managers
RN Care
Coordinators
Behavioral
Health
ConsultantEndocrinology
Results:
Does it Work??
Better Quality Outcomes
1.26% improvement of key WCHQ metrics
Experience of Care
6.9% increase in Top Box Likelihood of Recommending
Per Capita Costs
$209.32 more in Bellin payments per patient
$863.51 decrease in inpatient costs per patient
$24.08 lower PMPM (Medicare and Medicare Advantage patients)
Physician and Staff Satisfaction
92% satisfied with working at Bellin
Quadruple Aim
Results
Results based on 81 care teams live on team-based care greater then 1 year as of 5/1/2019
Quality Results
Colon Cancer Screening
56% to 71%
Breast Cancer Screening:
46% to 55%
Cervical Cancer Screening:
49% to 77%
AIC Control:
39% to 53%
Effect of
TBC on 5
Low
Performing
Teams
How are we
doing
compared to
expectations?
Expectations:
90% charts closed by 6 pm
Pre: 26% Post: 63%
Open Practice:
Pre 83% Post: 98%
4 RN visits per day:
Pre: 0 Post 3.5
So, How to
get
Started?
First, Build
the case for
Team-based
Care
• Improved quality measures lead to higher
value based reimbursements
• Decreased pmpm cost of care in team
based care favorable for risk based
payments
• Decreased burnout of staff leading to
improved staff retention, and decrease in
costs of staff replacement
• Enhanced recruiting as team based care
becomes recognized as a preferred model
of care
• Decrease in physician burnout leads to
improved patient care and less turnover
Goal #2:
Develop your
Model
• Advance skill set for all team members
• Make a list of all duties for each role
• Determine what work is below the top of
the skill set for each role and make
adjustments
• Relieve the EHR burden
• Decide on approach: Trained Scribe vs
Up-trained staff
• Magnify support for complex patients
• RN case managers, Clinical
Pharmacists, Diabetic Educators, Social
workers, Physical Therapists, etc. all
play a role
Then:
Get Started!
• Plan a small pilot with motivated team
• Develop training processes
• Plan for infrastructure needs
• Don’t forget to get baseline measures
• Spread slowly!!!
Prototype!
Is TBC only
for Large
Systems?
• Bellin is an independent, relatively small
community based system, no grant writers,
so no grants for this work
• Starting slowly can mitigate financial risk
• Regardless of practice size, every
physician needs EHR support, and
support when caring for complex patients
The #1 Question:
“How do you financially make this
work?”
56
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• Types of Contracts
Implement RN visits
Look for reimbursed
visits CCM TCM
Fee For
Service
Full
Risk
Increase
visits
Increase
coding
accuracy
Connect with
Community Resources
Grow Aligned
Lives
Decrease
Cost of Care
Answer: “Good Question!
There isn’t a simple answer.”
“We determined that hiring an additional MA for each
physician would pay for itself if each physician was
able to see just one additional patient per half-day
clinical session”
Kevin Hopkins M.D.
Cleveland Clinic
FPM Nov/Dec 2014
“Seeing one to two additional patients per half day
clinical session was sufficient to offset the
additional staffing costs once we factored in
downstream revenue”
Corey Lyon D.O.
University of Colorado
FPM March/April 2018
Increase
Coding
Accuracy
On average, each
HCC Code
identified adds
$2,600 to the
premium funding
In 2018 - 22,844 or 75% Medicare Wellness Visits Billed
8,120 or 36% were completed by RN’s
Gross Financial savings – $630,000
Goal for 2019 – 50% completed by RN’s
6
2
RN Visits
21% more likely Registered on
MyBellinHealth
60% more likely to have
Advanced Directive
1/3 Lower Healthcare Costs (PMPM)
46% Fewer Emergency Department Visits
Increased HCC Risk Score by
15%
Closed 6% more
Treatment Gaps
Closed 30% more Service
Gaps
Have a Primary Care Physician
(99.7%)
F I N D N G S
ANNUAL WELLNESS VISITS
People who had a wellness visit in 2016:
Patients who completed a Wellness Visit:• 43% in 2015 (NGACO
Only)• 55 % in 2016• 65% in 2017• 75% in 2018
6
4
Maximize Other
Sources of
Reimbursement
Chronic Care Management
Transitions Care
Management
New revenue source
6
5
Utilize Community
Resources
6
6
Grow Aligned
Lives
Aligned Lives for Bellin PCPs
Comparison between 2016 - 2018
Panel size growth = 8%
Primary Care visits =18%
increase
Inpatient admissions
= 5% decrease
Bellin Health:
Quality rank: # 1 2017
Shared Savings : 2016 - $1.4 Million
2017 - $ 5 Million
Participating Systems: 2016: 18
2017: 44
2018: 51
6
7
Bellin
Health:
Next Gen
ACO
data
Indirect Financial Considerations
Improved physician and staff engagement and ownership in quality
measurement results
Improved retention of physicians – a significant cost
savings
Improved Access
Enhanced ability to recruit as TBC spreads to residencies
Opportunity for advancing
staff
Improved efficiency of physicians
The Bottom Line
69
Total Cost for TBC in Primary Care
Staffing - $4.5 million annually($1.3
Million in additional staffing)
Reimbursement
Increase visits – $1,600,000
RN Visits – $630,000
CCM/TCM - $250,000
Value Based Reimbursement –
$2,500,000
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• Need to obtain leadership buy in: administration and physician leadership must work together
• Watch out for workflow demands on staff – Don’t offload physician's burnout onto staff
• MA recruitment can be a challenge
• Difficult for some physicians to let go of previous work, and to empower and trust staff in new roles: Change management needs to be addressed
• Challenges of training, and of sustaining change
• Takes time to develop true team culture – Co location really helps!
Challenges to
Anticipate
• Take time to build your prototype – Involve
frontline staff early on
• Don’t be afraid to adjust your model
• Don’t spread too fast
• Set clear expectations for all roles
• Focus on change sustainability
Lessons
Learned
• Consider infrastructure costs, such as for
co- location space
• Alleviating EHR demands on physicians
leads to less burnout, and better patient
care
• A team approach to in basket work gets
all staff working at the top of their skill set,
and provides more efficient care
• There has to be support for physicians in
the care of complex patients – utilize
community resources when possible
Lessons
Learned
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Fundamental truths that serve as the
foundation for a system of beliefs or
behaviors
1. Put the Patient first
2. Build team culture
3. Empower staff
4. Encourage critical thinking
5. Know your population
Guiding
Principles for
Successful
Team-based
Care
Notions or statements of an idea expressing
how something might be accomplished
1. Planned Care Principles
2. Enhanced rooming processes
3. Co location
4. Daily huddles
5. Regular care team meetings
6. Maximize use of warm handoffs
7. Effective use of extended care team
8. Standard documentation and
communication
9. Team approach to in between visit
work
10.Start on time
Core Concepts
for Successful
Team-based
Care
• In Search of Joy in Practice: A Report of 23 High-
Functioning Primary Care Practices.
Sinksy,C. et.al. Ann Fam Med 2013; 11:272-278
• From Triple to Quadruple Aim: Care of the Patient
Requires Care of the Provider.
Bodenheimer,T. Sinsky, C. Ann Fam Med 2014; 12:573-6
• A Team-Based Care Model That Improves Job
Satisfaction.
Lyon,C et al., Fam Prac Manag, 2018 25(2): p 6-11
• Helicopters and Hospitalizations: Getting the Primary
Care That We Invest In.
Sinsky, C. Annals of Int Med, February 2016 1-2
• Team-Based Care: Saving Time and Improving Efficiency.
Hopkins,K. Sinsky, C. FPM Nov/Dec 2014 ; 23-29
Recommended
Reading
• Allocation of Physician Time in Ambulatory Practices: A Time
and Motion Study in 4 Specialties
Sinsky,C et.al. Ann Int Med. 2016;165(11) 753-760
• RN Role Reimagined: How Empowering Registered Nurses
can improve Primary Care
Bodenheimer,T Et. al. California Healthcare Foundation 2015
• Medical Scribes - How do their notes stack up?
Misra-Hebert AD, et.al. J Fam Prac 2016 65(3): 155-159
• Estimates of Costs of Primary Care Turnover
Buchbinder,SB et. al. Am J Managed Care 1999 Nov:5(11) 143-8
• Using Empowered CMAs and Nursing Staff to Improve Team-
based care
Jerzak,J Fam Prac Manag. January/February 2019; 17-22
Recommended
Reading